Table of Contents

Abstract

Little is known about physical rehabilitation and brace treatment of patients with hyperkyphosis. Physical therapy (or physiotherapy) for postural improvement is often recommended, especially in central Europe, focusing on pectoralis and hamstring stretching and trunk extensor strengthening as well as improving function. These exercises are also described within the Schroth program.

Bradford et al. have found their attempts effective, treating Scheuermanns kyphosis with Milwaukee braces and exercises, but their report did not focus on in-brace corrections in their first study. White and Panjabi's research aimed to try to correct a curvature of > 50° with the help of distraction forces, but consequent patient comfort was greatly reduced in the application of the Milwaukee brace used to treat this condition in the U.S. In modern bracing concepts they avoid this by utitlising braces to treat hyperkyphosis that use transverse correction forces instead of distraction forces. Further efforts to reduce brace material have resulted in a special bracing design called kyphologic™ brace.

If we may assume that outcome of brace treatment positively correlates with in-brace correction the treatment should be initiated before the curvature angle exceeds 50 - 55° in a growing adolescent. In scoliosis bracing if the average in-brace correction equals > 15° then it is predicted that the result will lead to a correction. In its application for hyperkyphosis patients the average in-brace correction with this brace was also > 15°. Therefore we estimated to achieve a favourable outcome using this brace type once compliance was attained, especially when comparing the correction effects achieved with this new approach to the correction effects reported upon using the Milwaukee brace, successfully. The latter brace has been shown to lead to beneficial outcomes in long-term with comparable in-brace corrections. For lumbar and thoracolumbar curve patterns other approaches of physiotherapy and bracing are recommended. These are described in this paper as well.

Conservative treatment of Scheuermann's hyperkyphosisin international literature is regarded as being effective. Physiotherapy and bracing are the treatments of choice.

An average in-brace correction of > 15° as was achieved with the help of the kyphologic™ brace seems to predict a favourable outcome. In thoracolumbar and lumbar curve patterns physio-locic™ ecercises as well as the physio-locic™ brace are recommended according to international literature. In kyphosis management, due to the benign character of the deformity - in-patient rehabilitation does not seem necessary.

Future studies should focus more on thoracolumbar and lumbar curve patterns, because these patterns may predict chronic low back pain in adulthood with reduced quality of life of the patients and high costs with respect to medical care and sick leave.

Surgery, according to international literature, is rarely necessary in this condition.

Background

Scheuermann's disease initially was described as a rigid kyphosis associated with wedged vertebral bodies occurring in late childhood (Scheuermann 1920).

Scheuermann's disease has been of significant orthopedic interest in the past, because it sometimes may be painful during its relative acute phase and more importantly, because it may cause significant truncal deformity that can progress. Sorensen subsequently described specific criteria for diagnosis in 1964 (Sorensen 1964), namely, that three adjacent vertebrae must be wedged at least 5° each.

Others articles have used different criteria. These include increased thoracic kyphosis, disc space narrowing and irregular endplates associated with a single-wedged vertebra (Bradford 1980, Halal and Gledhill 1978), a kyphosis of greater than 45° with two or more wedged vertebra (Gutowski and Renshaw 1988), or "characteristic" radiographic findings (kyphosis, wedging of vertebral bodies, endplate irregularities, Schmorl's nodes, see Fig. 1.) (Stoddard and Osborn1979, Taylor et al. 1979).

Wenger and Frick (1999) have published an extensive review on this condition, but when looking into recent Pub Med listings, these conditions seem to stimulate less scientific interest. The last review on this topic has been published recently (Weiss, Turnbull and Bohr 2009)

There are some points of discrepency upon the definition of the pathological deviations of normal and sagittal spinal alignment (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). Unlike scoliosis, where any significant lateral deviation in the coronal plane is abnormal, the sagittal alignment of the spine has a normal range of thoracic kyphosis. The Scoliosis Research Society has defined this range as being from 20° to 40° in the growing adolescent (Tribus 1998, Wenger and Roundback 1993, Lowe 1990). In a study of 316 healthy subjects with ages ranging from 2 to 27 years, the upper limit of normal kyphosis was noted to be 45°. It was also noted that the average thoracic kyphosis increases with age from 20° in childhood, to 25° in adolescents, to 40° in adults (Fon, Pitt and Thies 1980). The lack of a consistent definition of Scheuermann's kyphosisin the literature makes it difficult to compare studies as the inclusion criteria may be different; thus, making the distinction between the spectrum of upper normal thoracic kyphosis, severe adolescent roundback deformity, and Scheuermann's disease almost impossible (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009).

Little is known about the lumbar or thoracolumbar pattern of Scheuermann's disease. The Schmorl's nodes and endplate irregularity may be so severe that the lower lumbar Scheuermann's disease can be confused with infection, tumor, or other conditions (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009) (Fig. 2.). The etiology of lumbar Scheuermann's kyphosisis unknown, but strong associations with repetitive activities involving axial loading of the immature spine favor a mechanical cause (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). Although the radiographic appearance may be similar, lumbar Scheuermann's kyphosisis regarded a different entity than thoracic Scheuermann's kyphosis(Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). Unlike classic thoracic Scheuermann kyphosis, the treatment of lumbar Scheuermann's disease was not controversial in 1999 (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009), as its course has been regarded as being nonprogressive and its symptoms have been regarded to resolve with rest, activity modification and time (Blumenthal, Roach and Herring 1980, Greene, Hensinger and Hunter 1985).

However, this loss of lumbar lordosis, in this area of lumbar or thoracolumbar means that Scheuermann's disease can be one of the predictors of developing chronic low back pain in adulthood:

Loss of lumbar lordosis correlates well with the incidence of chronic low back pain in adulthood (Glassman et al. 2005, Djurasovic and Glassman 2007). Sedentary lifestyle contributes to loss of lumbar lordosis as well as scoliosis and thoracolumbar or lumbar kyphosis (Weiss and Werkmann 2009). It is necessary to recognise that the severity of symptoms in patients with back pain, as they increase in a linear fashion with progressive sagittal imbalance. The results of these studies also show that hyperkyphosis is more favourable in the upper thoracic region but very poorly tolerated in the lumbar spine (Glassman et al. 2005, Djurasovic and Glassman 2007, Weiss and Werkmann 2009). As it has been shown, lumbar re-lordosation stabilizes the spine with respect to lateral deformity (van Loon, Kühbauch and Thunnissen 2008, Weiss and Werkmann 2009), so we may assume that lumbar de-lordosation or lumbar kyphosis destabilizes the spine and can lead to chronic low back pain (Weiss and Werkmann 2009b). Therefore 10 years after the review by Wenger and Frick (Wenger and Frick 1999), lumbar Scheuermann's disease needs to be investigated focussing upon the prevention of chronic low back pain in adulthood (Weiss, Turnbull and Bohr 2009).

According to Wenger and Frick (Wenger and Frick 1999) the incidence of Scheuermann's disease has been estimated at 1 to 8% of the population (Sorensen, 1964, Scoles et al. 1991). The typical presentation is in the late juvenile age period from 8 to 12 years, with the more severe fixed form commonly appearing between age 12 and 16 years. Patients with thoracic roundback, who have classic type I Scheuermann disease, may have pain in the thoracic spine area, but more frequently present because of patient and parental concerns related to trunk deformity. The gender prevalence of Scheuermann's kyphosisis difficult to determine from the literature, and may be related to how Scheuermann's kyphosisis defined. In general, males and females are involved with equal frequency (Tribus 1998), although the reported ratios have varied widely (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009).

Patients with Scheuermann's kyphosishave an angular thoracic kyphosis (Fig. 3.), often with accompanying compensatory lumbar lordosis and increased cervical lordosis. The position of the head is often in forward protrusion (also known as gooseneck), and the shoulders are often positioned anteriorly. Forward bending typically accentuates the kyphotic deformity, with a sharply angulated bend noted in the thoracic or thoracolumbar region. The deformity is relatively fixed, remaining during attempted hyperextension of the spine. Tightness of the hamstrings is common, but the neurologic exam is usually otherwise normal (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009).

Unfortunately Wenger and Frick (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009) do not describe the clinical findings of other curve pattern than thoracic Scheuermann, although the thoracolumbar and lumbar Scheuermann curve patterns are of major importance with respect to chronic low back pain in adulthood (Weiss and Werkmann 2009, Weiss and Werkmann 2009b). There seems to be less coverage of these curve patterns in the literature of Pub Med.

The degree of kyphosis on the lateral film is measured using a modified Cobb method according to Stagnara (Stagnara et al. 1982, Weiss and ElObeidi 2008). In addition to increased measurable roundback on the lateral view, vertebral wedging is used to clarify the diagnosis. Associated findings of scoliosis and spondylolysis can occur with Scheuermann kyphosis, but usually are minor and do not alter treatment (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009).

Natural History

The natural history of Scheuermann's disease remains controversial. The condition tends to be symptomatic during the teenage years but often in late teenage life produces less pain Sorensen 1964). In a long term follow-up study, Sorensen noted pain in the thoracic region in 50% of patients during adolescence, with the number of symptomatic patients decreasing to 25% after skeletal maturity (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). The pain was described as mild and not incapacitating. Later authors offered a contrasting view of the symptoms of untreated Scheuermann disease, with Bradford stating that adults with Scheuermann's kyphosishave a higher incidence of disabling back pain than the normal population (Bradford et al. 1980, Bradford et al. 1975).

Murray, Weinstein, and Spratt have performed a study designed to describe the natural history of Scheuermann's kyphosis (Murray, Weinstein and Spratt 1993). They studied 67 of a group of 118 (57%) patients diagnosed by the Sorenson criteria, using physical examination, trunk strength measurements, radiography, a detailed questionnaire and pulmonary function testing (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). The patients had an average kyphotic deformity of 71°, and the average follow-up was 32 years; an age-matched comparison group was used as controls. They concluded that patients with Scheuermann's kyphosismay have functional limitations, but these did not result in severe limitations due to pain, or cause major interference with their lives (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). Yet in another paper, Lowe and Kasten state that adults with more severe deformities (>75°) secondary to untreated Scheuermann's disease can have severe thoracic pain secondary to degenerative spondylosis and can be significantly limited by their disease (Lowe and Kasten 1994). The authors allude to the greater magnitude of the deformity as a possible explanation for the life-altering pain experienced by their patients as contrasted to those reported on by Murray et al., although studies to document a direct correlation between the amount of pain and the degree of deformity are not available (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009).

The common indications for treatment in Scheuermann's kyphosisare related to pain, progression of deformity and appearance. Pain is difficult to measure because of its subjective and temporal nature (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). Most of the literature on Scheuermann's kyphosisstates that pain is either present or absent, and does not provide data on how this was determined or measured (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). The study by Murray et al. (Murray, Weinstein and Spratt 1993) is the only single attempt in the literature to objectively assess pain in this patient group. They found no statistically significant difference between the Scheuermann patients and the control group with regard to the extent that pain interfered with their lives, although it is possible that a clinically significant difference might exist as 38% of the Scheuermann patients had severe interference of pain with activities of daily living compared to 21% of control subjects. The kyphotic group did have significantly higher pain intensity readings, and complained more frequently of pain in the thoracic region than the control group. Patients with Scheuermann kyphosis, however, were no more likely to take medications for back pain. They were able to study only 57% of the patients with Scheuermann kyphosis, and their statistics might be quite different if more patients were available for a follow-up study.

Tribus has outlined the reasons for treatment of Scheuermann's kyphosisalso for cardiopulmonary compromise (Tribus 1998). Deformity is the most common complaint of patients with Scheuermann disease, and is typically the primary reason younger patients seek medical attention (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). However, the likelihood of progression of a kyphotic curve of any given degree of severity is currently not known (Otsuka, Hall and Mah 1990).

Studies reporting on the natural history of lumbar and thoracolumbar Scheuermann's disease have not been cited by Wenger and Frick (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009) and do not seem to ba available when searching Pub Med in 2009.

Treatment

Initial management of the patient presenting with Scheuermann's kyphosisincludes documentation and assessment of the degree of deformity and/or pain, as well as an overall picture of the negative impact of the deformity on the patient's life (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). Physical therapy (or physiotherapy) for postural improvement exercises is often recommended, especially in central Europe, focusing on hamstring stretching and trunk extensor strengthening as well as improving function (Weiss, Dieckmann and Gerner 2003). A good physical therapist can also assess whether there is any tendency toward increased hip flexion contracture and may work on associated lumbar lordosis (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). There are no conclusive studies documenting improvement in kyphosis with exercises (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009), although Bradford et al. did note some improvement in patients with moderate degrees of deformity (Bradford et al. 1974).

Scheuermann's disease in adults is regarded to be a different entity from that of the teenager for the major manifestation is pain and not aesthetic quality. The patient's occupation is rather sedentary; sport is beneficial. The functional rehabilitation is the basic treatment and recourse to surgery or dorso-lumbar braces is rare (Ghoussoub et al. 2004).

According to Pizzutillo (Pizzutillo 2004) effective interventions for adolescents with postural kyphosis include exercises to relieve lower extremity contractures and strengthen abdominal musculature coupled with practiced normal posture in stance and in sitting. Skeletally immature patients with Scheuermann's kyphosis benefit from a similar exercise program but also require the use of a spinal orthosis. Bracing of the spine in patients with Scheuermann's kyphosis results in permanent correction of vertebral deformity, unlike bracing in patients with idiopathic scoliosis. The evaluation of children and adolescents with increased thoracic kyphosis is an important aspect of the decision process used to determine appropriate interventions (Pizzutillo 2004).

Physiotherapy for hyperkyphosis

Physiotherapy for patients with thoracic kyphosis has been described at length by Lehnert-Schroth (Lehnert-Schroth and Weiss 1992, Lehnert-Schroth 2000). This kind of exercises, however does not differ a lot from what is described in literature.

Stretching of pectoralis muscels, passive and active redression of the kyphotic hump are the main principles of physical exercises besides the work on the lower extremity muscles within the Schroth exercise program. Especially the "two stool" exercise as shown on Figure 4 and the "door frame exercise" (Fig. 5) shows elements of muscle stretching and redression of the thoracic kyphosis.

Thoracolumbar and lumbar curve patterns have to be addressed differently by physiotherapy: loss of lumbar lordosis is the consequence of these curve patterns, which, according to actual knowledge, is directly related to chronic low back pain in adulthood.

Therefore loss of lumbar lordosis in these curve patterns exercises should aim to correct. Exercises to improve lumbar lordosis have been described at length by ourselves (Weiss and Klein 2006). These exercises are called physio-logic™ exercises as they are developed to restore a physiologic lumbar lordosis and by this best possible lumbar function and stability.

In the recent years kyphosis patients were treated with a four week in-patient rehabilitaion program, especially in Germany. In view of the benign character of the disease and the lack of evidence there is for in-patient rehabilitation in general in-patient rehabilitation does not seem necessary or even indicated.

Brace Treatment for hyperkyphosis

The few available studies on efficacy of brace treatment are retrospective, have different inclusion criteria, and do not have control groups. In addition, as noted above, we do not yet have data available to allow us to predict which kyphotic curves are at significant risk for progression (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009). Despite these shortcomings, bracing is widely regarded as being efficacious in the treatment of Scheuermann's kyphosisin the skeletally immature patient (Tribus 1998, Lowe 1990). Bracing has been used primarily for the treatment of deformity, with results of treatment focusing on improvement in kyphosis; the results of brace treatment for relieving pain have not yet been published (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009).

The initial report of Bradford et al. on Milwaukee brace treatment (Fig. 8) of Scheuermann's kyphosisin 75 patients, who had completed treatment, documented a 40% decrease in mean thoracic kyphosis and a 35% decrease in mean lumbar lordosis after an average 34 months of brace wear (Bradford et al. 1974). A later study from the same center (Sachs et al. 1987) reporting on 120 of 274 patients treated with a Milwaukee brace for Scheuermann's kyphosis showed a pattern of initial correction of approximately 50% of the kyphosis (when setting the estimated normal value as 0; Hefti and Jani 1981) followed by loss of correction. Similar findings have been reported by Montgomery and Erwin (1981).

Gutowski and Renshaw (1988) have reported on the use of the Boston lumbar and modified Milwaukee orthoses for Scheuermann's kyphosisand abnormal juvenile round back with an average 26-month follow-up. Of 75 patients in their study group, 31% completely rejected the orthosis within 4 months. Compliant patients had an average improvement in kyphosis of 27% in the Boston group and 35% in the Milwaukee group, despite use of the Milwaukee brace for older patients who had greater curves (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009).

According to Lowe (Lowe 2007, Lowe and Line 2007) brace treatment is almost always successful in patients with kyphosis between 55 degrees and 80 degrees if the diagnosis is made before skeletal maturity. Kyphosis greater than 80 degrees in the thoracic spine or 65 degrees in the thoracolumbar spine is almost never treated successfully without surgery in symptomatic patients. Surgical treatment in adolescents and young adults should be considered if there is documented progression, refractory pain, loss of sagittal balance, or neurologic deficit.

The patients treated with a brace often face problems with their relations with friends, while they reported difficulties in getting up from bed and sleep at night more often than their counterparts without deformities as pointed out by Korovessis et al. (2007). As they grow older, patients feel increasing ashamed of their body, as they are more concerned about the future effect of the deformity on their body. As the bracing time increases, patients have much more probability than controls to get low back pain. Girls with deformity have a higher probability than boys to get low back pain. Individuals with larger spinal curvatures have more difficulties in bending and increased incidence of back pain than their counterparts with smaller curvatures. Psychological reasons associated mainly with relations at school and back pain are the main causes for low compliance in adolescents with spinal deformities treated with body orthosis. Careful instructions for all individuals who will undergo brace therapy, psychological support for all patients who develop psychological reactions and physical training particularly for older girls should be recommended to increase bracing compliance (Korovessis et al. 2007).

A newly designed brace in the treatment of adolescent Scheuermann thoracic kyphosis has been proposed by Riddle et al. (2003). However, the authors did not report on in-brace corrections.

Twenty-two children who met the roentgenographic criteria of Scheuermann's kyphosisand were compliant with treatment were followed until skeletal maturity. Sixteen patients (73%) showed nonprogression of their kyphosis (nine patients demonstrated an improvement, seven patients remained unchanged), and had a mean improvement of 9 degrees (64 degrees to 55 degrees). Six patients (27%) demonstrated progression of the kyphosis and had a mean increase in their kyphosis of 9 degrees (59 degrees to 68 degrees). One patient underwent posterior spinal fusion for progressive thoracic kyphosis despite bracing. It was recommended that this brace be worn until skeletal maturity; in this study the time period was determined to be at least 16 months to induce improvement or halt progression of this disease. Flexible curves are a positive predictor of a successful outcome of bracing with the kyphosis brace. These results are comparable to previous reports in the literature describing the effectiveness of the modified Milwaukee brace in the treatment of Scheuermann thoracic kyphosis prior to skeletal maturity, and the kyphosis brace has the advantage of concealability under normal attire (Riddle et al. 2003).

Historically, brace treatment in central Europe has been different, although in the seventies the Milwaukee brace was used for the treatment of Scheuermann's kyphosisin Germany as well, but at the same time also the Gschwend brace was used (Krähe and Zielke 1986). A permanent correction of kyphosis has been reported using the Gschwend-brace (Fig. 9.) when the therapy started early, lasted long enough in patients with good compliance (Raeder 1987).

Other bracing strategies have been tried like the use of a soft brace, however these have not been shown to be successful (Fig. 10.).

Variation of vertebral morphology in Scheuermann's Kyphosis before and after orthopaedic treatment is usually measured by the entity of the curve, using Cobb's method, and by vertebral wedging. But the lack of correlation between these parameters and the clinical evolution of the deformity, lead to the possibility that other variables may explain the reason of the kyphosis deformities before and after the treatment. In this group of alterations the inclination of anterior and posterior walls, that express the trapezoid deformity of vertebras, seem to be more reliable indicators of curve response to orthopaedic treatment (Pola et al. 2002).

Results of modern braces used for the treatment of kyphosis have also been documented in a recent textbook on spinal deformities (Weiss 2003). In order to improve the patients quality of life whilst wearing the brace and by that improving compliance as well, attempts have been made to reduce material without losing the in-brace correction desired (Weiss 2005). This brace, known as the kyphologic™ brace, was developed in 2005 and meanwhile is applied to a number of kyphosis patients (Fig. 11 and Fig. 12.).

Little is known about the in-brace correction effects of braces used for the treatment of kyperkyphosis. While Bradford et al. (Bradford et al. 1974, Bradford et al. 1975, Sachs et al. 1987) have found their attempts effective, treating Scheuermanns kyphosis with Milwaukee braces, they did not widely report on in-brace corrections. According to White and Panjabi (1976) it seems the appropriate approach to try to correct a curvature of > 50° with the help of distraction forces; however, patient comfort is largely reduced in the Milwaukee brace. Therefore, in Germany braces generally prescribed for hyperkyphosis treatment are using transverse corretion forces only. Efforts to reduce brace material have resulted in a special bracing design called kyphologic™ brace as described above. This brace has been shown to have a good in-brace correction at average and, additionally to that, is smaller than other braces used in the treatment of thoracic kyphosis so far (Weiss, Turnbull and Bohr 2009)

The kyphologic™ brace (Weiss, Turnbull and Bohr 2009), like the Gschwend type braces (Krähe and Zielke 1986), uses two 3-point pressure systems. The first of the two 3-point pressure systems includes the sacral pad dorsally, the subpectoral ribbow pressure area ventrally and the thoracic (apical) pressure area dorsally. The second 3-point system includes the subpectoral ribbow pressure area ventrally, the thoracic (apical) pressure area dorsally and the two pads redressing the shoulder girdle from verntral aiming at the cavity of the coracoid process (Fig. 11, Fig. 12, Fig. 13, Fig. 14, Fig. 15). The upper closure strap is directly improving the pressure on the lower ribs so as to inhibit protrusion of the lower ribbows, while the lower closure is just for better pelvic fixation.

Discussion

If we assume that outcome of brace treatment positively correlates with in-brace correction the treatment should start before the curvature angle exceeds 50° in patients continuing to grow. In scoliosis bracing an average in-brace correction of > 15° predicts an end result correction (Sachs et al. 1987). At average with this brace we have achieved > 15° also in kyphosis treatment. Therefore we estimate to achieve a favourable outcome using this brace type when compliance can be gained.

The kyphologic™ brace leads to in-brace corrections comparable to those of the Milwaukee brace, which have been shown to lead to a beneficial outcome in the long-term (Sachs et al. 1987, Hefti and Jani 1981, Montgomery and Erwin 1981, Gutowski and Renshaw 1988, Riddle et al. 2003, Pizzutillo 2004, Lowe 2007, Lowe and Line 2007).

These results have been achieved with much less brace material and with much less compromise of quality of life of the patients treated (Fig. 13, Fig. 14, Fig. 15). Therefore the Milwaukee brace, although leading to beneficial outcomes, as to our opinion has to be regarded as outdated today.

The Gschwend type braces, with full pelvic coating, in kyphosis treatment are no longer necessary. When trying to correct a kyphosis, lateral pelvic support does not seem to be necessary, when the counter forces acting are focused specifically upon the sagittal plane.

A few patients from this study with follow-up periods of more than one year have been registered. There was one boy with an in-brace correction of 30 degrees who has been corrected 30 degrees (without the brace on) before he needed a new brace (Fig. 16).

Another patient is demonstrated on Fig. 17 with an improved curve after 9 months of treatment (16 hrs per day) and in the new brace a furtherly improved curvature correction.

Findings like this lead us to the presumption that also final corrections 2 years after weaning should be possible. Nevertheless, a prospective follow-up study seems desirable before final conclusions can be drawn.

There are other curve patterns than thoracic ones. We distinguish between

thoracic

thoracolumbar

lumbar

And hyperkyphosis or Scheuermann desease. The kyphologic™ brace as it is described is indicated for the treatment of thoracic kyphosis only. We have been trying to develop a kyphologic™ brace for thoracolumbar kyphosis patterns (Fig. 18), however the results achieved were not comparable to those we were able to achieve in thoracic kyphosis (Fig. 19). This is why we now treat thoracolumbar curves with the physio-logic™ brace aiming at a reduction of lumbar kyphosis in order to allow a restoration of lumbar lordosis. This does not lead to major correction effects, as it only shifts the kyphosis to cranial (curvature phase shift). With respect to the fact that the loss of lumbar lordosis is not favorable in the long-term [19,20] , pain prevention seems more important than cosmesis in this curve pattern.

Lumbar kyphoses are treated with the physio-logic™ brace (Fig. 20 and Fig. 21) for the same reasons. In-brace corrections for this rare pattern of Scheuermann desease, however have not been investigated, yet.

As previously reported (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009), surgical interventions (Fig. 22) come with increased risks. Nevertheless recent publications seem to support surgery (Lim et al., 2004, Atici et al. 2004). As there is a consensus, that surgery is rarely necessary because conservative management is highly effective (Wenger and Frick 1999, Weiss, Turnbull and Bohr 2009), it is necessary to improve the conservative standards of treatment. To improve the compliance for conservative treatment and therefore developing a bracing design with less materials but promising in-brace correction seems a step towards improving correction effects.

There is little literature available in Pub Med about the current concepts of physiotherapy for hyperkyphosis. Although there is little evidence that physiotherapy alone can change the natural history of the disease, it is common sense to use certain exercises for the treatment of thoracic curve patterns (Bradford et al. 1974, Bradford et al. 1975, Sachs et al. 1987).

Lumbar curve patterns according to present knowledge have to be treated differently (Weiss, Turnbull and Bohr 2009). Until now there is no evidence for the treatment of lumbar Scheuermann with physio-logic™ exercises, the sagittal profile of lumbar and thoracolumbar Scheuermann is not very different to that of patients with scoliosis. In the latter condition the physio-logic™ exercises have been shown to be beneficial and this is why there is good reason to assume they will also be beneficial for lumbar kyphoses without scoliosis (Weiss, Turnbull and Bohr 2009).

Conclusions

Rehabilitation of Scheuermann's hyperkyphosis in international literature is regarded as being effective. Physiotherapy and bracing are the treatments of choice, however more intensive procedures of rehabilitation rarely seem necessary.

An average in-brace correction of > 15° as was achieved with the help of the kyphologic™ brace seems to predict a favourable outcome.

The kyphologic™ brace leads to in-brace corrections comparable to those of the Milwaukee brace, which has previously been shown to provide beneficial outcome in the long-term.

Future studies should focus more on thoracolumbar and lumbar curve patterns, because these patterns may predict chronic low back pain in adulthood with reduced quality of life of the patients and high costs with respect to medical care and sick leave. For chronic low back pain in patients with thoracolumbar and lumbar curve patterns more intensive programs of rehabilitation may be necessary, but today there are not enough data focussing on this subject.

Surgery according to international literature is rarely necessary in this condition.

Acknowledgements

Written informed consent was obtained from the patients for publication of their cases.

Figures

Figure 1. Scheuermann signs on a lateral x-ray.

Characteristic radiographic findings in a patient with Scheuermann's disease in the late stage (kyphosis, wedging of vertebral bodies, endplate irregularities, Schmorl's nodes, from Weiss, Turnbull and Bohr 2009)

Figure 2. Scheuermann signs on a lateral x-ray in the thoracolumbar region.

The Schmorl's nodes and endplate irregularity may be so severe that lumbar Scheuermann's disease can be confused with infection, tumor, or other conditions (Weiss, Turnbull and Bohr 2009).

Figure 3. Lateral view of a patient with severe Scheuermann disease.

Patients with Scheuermann's kyphosishave an angular thoracic kyphosis, often with accompanying compensatory lumbar lordosis and increased cervical lordosis. The position of the head is often in forward protrusion (so called gooseneck), and the shoulders are often positioned anteriorly as well (Weiss, Turnbull and Bohr 2009).

Figure 4. The "two stool" exercise for the redression of a thoracic kyphosis and pectoral stretching accordingly.

Figure 5. The "door frame" exercise for the redression of a thoracic kyphosis and pectoral stretching accordingly.

Figure 6. physio-logic™ exercise on the wallbars.

Lumbar lordosis is enforced by a fulcrum and the synergy effects of shoulder inner rotation improves the counter kyphosation in the thoracic area.

Figure 7. physio-logic™ exercise on the floor.

Lumbar lordosis is enforced by a fulcrum and kyphosation is improved in the thoracic area.

Figure 8. Milwaukee braces in different patients.

These braces have been used for the treatment of patients with scoliosis in the 70es here in Germany, however for the treatment of kyphosis the Gschwend type braces have been used. Therefore no Milwaukee brace used for a patient with kyphosis is available in our data base. Nevertheless the traction in these braces is clearly visible (Weiss, Turnbull and Bohr 2009).

Figure 9. Dorsal aspect of a Gschwend type brace as used in Germany.

Still today this kind of brace is used for the treatment of thoracic kyphosis (Weiss, Turnbull and Bohr 2009).

Figure 10. Soft brace in the treatment of a rigid kyphosis.

Obviously no correction can be achieved using a soft brace in rigid curvatures. In the kyphologic™ brace, as can be seen on the right, a clinical correction has been achieved in the same patient (Weiss, Turnbull and Bohr 2009).

Figure 11. Patient with rigid kyphosis in a kyphologic™ brace.

Patient with rigid kyphosis without and in a kyphologic™ brace. The in-brace correction is good and after the first 6 weeks of treatment the curve was flexible again so as to allow to reduce brace wearing time to 16 hrs. / day (Weiss, Turnbull and Bohr 2009).

Figure 12. Another patient with rigid kyphosis in a kyphologic™ brace.

Patient with rigid kyphosis without and in a kyphologic™ brace. The in-brace correction is good and after the first 6 weeks of treatment - as in most of the patients treated with this brace - the curve was flexible again so as to allow to reduce brace wearing time to 16 hours / day as well (Weiss, Turnbull and Bohr 2009).

Figure 13. A good in-brace correction in a patient with rigid kyphosis in a kyphologic™ brace.

Patient with rigid kyphosis without and in a kyphologic™ brace. The in-brace correction is > 20° and therefore can be regarded as being sufficient for an end-result improvement when compliance can be achieved (Weiss, Turnbull and Bohr 2009).

Figure 14. Another patient with good in-brace correction in a kyphologic™ brace.

Patient with rigid kyphosis in a kyphologic™ brace. The in-brace correction is > 20° in this patient as well (Weiss, Turnbull and Bohr 2009).

Figure 15. A good in-brace correction in a patient with rigid kyphosis in a kyphologic™ brace showing a release of the anterior growth plates.

Patient with rigid kyphosis in a kyphologic™ brace. The in-brace correction is > 20° and on the right picture the opening of the intervertebral spaces is visible. Therefore we can expect an end result correction when the brace is worn, because the ventral growth plates have been released from pressure (Weiss, Turnbull and Bohr 2009).

Figure 16. Correction achieved within 15 months of treatment.

The in-brace correction has been 30° and before a new brace has been made the curve was 33° whereas initially we have measured > 60°. The sagittal surface topography reconstruction can be seen in the black frame on the left: Upper picture at the start of treatment, middle picture after 6 months of treatment and lower picture after 15 months. A straightening of the spine in sagittal plane is clearly visible (Weiss, Turnbull and Bohr 2009).

Figure 17a. In-brace correction in the first brace of a patient with rigid kyphosis.

The correction was from 50° initially to 27° in the first brace (Weiss, Turnbull and Bohr 2009).

Figure 17b. In-brace correction in the second brace of the patient from figure 13a.

In the second brace the curve has been corrected from 35° to 18° and the curve was no more stiff. However as there was still growth left we adjusted a new brace for 8-12 hours / day (Weiss, Turnbull and Bohr 2009).

The correction effects in low thoracic and thoracolumbar curve patterns were far from being satisfying. Therefore we will not offer this kind of braces any longer (Weiss, Turnbull and Bohr 2009).

Figure 19. Lateral x-rays of a patient with thoracolumbar kyphosis.

Left: lateral x-ray without brace, middle: lateral x-ray in the kyphologic™ brace model for thoracolumbar kyphosis without any significant effect. Right: In the physio-logic™ brace at least the lumbar lordosis is restored giving the sagittal view a more physiologic pattern (Weiss, Turnbull and Bohr 2009).

Figure 20. physio-logic™ braces of the first series from 2004.

The physio-logic™ brace aims at a restoration of the lumbar lordosis with a lordosis apex at L2 or L2/3 level (Weiss, Turnbull and Bohr 2009).

Figure 21. Patient with lumbar Scheuermann in the physio-logic™ brace.

Improvement of lumbar lordosis is visible. Due to curve stiffness the in-brace correction seems moderate, however clinically the brace effect is visible as well (Weiss, Turnbull and Bohr 2009).

Figure 22. Patient operated for a severe thoracic kyphosis.

The patient is satisfied with respect to clinical (cosmetic) appearence and has no pain in the region of the rod fracture (lower right). However she suffers from pains in the junctional zones and has daily pains in the lower back below the fusion area and abobe the fused area in the lower neck as well. This pain is increasing during the years (Weiss, Turnbull and Bohr 2009).

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This publication of the Center for International Rehabilitation Research Information and Exchange is supported by funds received from the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education under grant number H133A050008. The opinions contained in this publication are those of the authors and do not necessarily reflect those of CIRRIE or the Department of Education.